MEDICARE: SHANA LYNN WATSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	1640	VA

General Provider Information

NPI Number	:	1114206216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANA LYNN WATSON

Provider Business Mailing Address
First Line	:	6767 FOREST HILL AVE
Second Line	:	SUITE 301
City	:	RICHMOND
State	:	VA
Zip	:	23225-1856
Country	:	US
Telephone Number	:	804-901-7823
Fax Number	:	804-901-7823

Provider Business Practice Location Address
First Line	:	6767 FOREST HILL AVE
Second Line	:	SUITE 301
City	:	RICHMOND
State	:	VA
Zip	:	23225-1856
Country	:	US
Telephone Number	:	804-901-7823
Fax Number	:	804-901-7823

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2011
Last Update Date	:	08/30/2011

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